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Background: Self-harm (any self-injury or -poisoning regardless of intent) is highly prevalent in transgender and gender diverse (TGD) populations. It is strongly associated with various adverse health and wellbeing outcomes, including suicide. Despite increased risk, TGD individuals' unique self-harm pathways are not well understood. Following PRISMA guidelines we conducted the first systematic review of risk and protective factors for self-harm in TGD people to identify targets for prevention and intervention. Methods: We searched five electronic databases (PubMed, PsychInfo, Scopus, MEDLINE, and Web of Science) published from database inception to November 2023 for primary and secondary studies of risk and/or protective factors for self-harm thoughts and behaviours in TGD people. Data was extracted and study quality assessed using Newcastle-Ottawa Scales. Findings: Overall, 78 studies published between 2007 and 2023 from 16 countries (N = 322,144) were eligible for inclusion. Narrative analysis identified six key risk factors for self-harm in TGD people (aged 7-98years) were identified. These are younger age, being assigned female at birth, illicit drug and alcohol use, sexual and physical assault, gender minority stressors (especially discrimination and victimisation), and depression or depressive symptomology. Three important protective factors were identified: social support, connectedness, and school safety. Other possible unique TGD protective factors against self-harm included: chosen name use, gender-identity concordant documentation, and protective state policies. Some evidence of publication bias regarding sample size, non-responders, and confounding variables was identified. Interpretation: This systematic review indicates TGD people may experience a unique self-harm pathway. Importantly, the risk and protective factors we identified provide meaningful targets for intervention. TGD youth and those assigned female at birth are at increased risk. Encouraging TGD people to utilise and foster existing support networks, family/parent and peer support groups, and creating safe, supportive school environments may be critical for self-harm and suicide prevention strategies. Efforts to reduce drug and alcohol use and experiences of gender-based victimisation and discrimination are recommended to reduce self-harm in this high-risk group. Addressing depressive symptoms may reduce gender dysphoria and self-harm. The new evidence presented in this systematic review also indicates TGD people may experience unique pathways to self-harm related to the lack of social acceptance of their gender identity. However, robust longitudinal research which examines gender-specific factors is now necessary to establish this pathway.
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PURPOSE: Although cross-sectional studies have demonstrated that trans people present with lower quality of life and wellbeing than the general population, few studies have explored the factors associated with this, particularly in those who have medically transitioned some time ago. This paper aims to fill the gap in the literature on what factors are associated with wellbeing in trans people who initiated medical transition some time ago. METHODS: This study used semi-structured one-to-one interviews with 23 participants to investigate the factors that impact upon the wellbeing of trans people who had initiated Gender Affirming Medical Treatment five or more years ago. The content of the interviews were analysed with an inductive, grounded theory approach to identify common themes within them. RESULTS: The four themes identified include some consistencies with cisgender populations (while being viewed through the lens of trans experience), as well as those more specific to the trans experience. Together these themes were: Interactions with healthcare services; Seeking societal acceptance; Quality of social support; The 'double-edged sword' of media and social media. Each of the themes identifies a factor that participants highlighted as impacting, either positively or negatively, on their wellbeing. CONCLUSIONS: The results highlight the importance of social support, protective legislations, awareness of trans issues in the general public, and the need of improving the knowledge held by non-specialist healthcare providers.
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Pessoas Transgênero , Estudos Transversais , Identidade de Gênero , Humanos , Pesquisa Qualitativa , Qualidade de Vida/psicologiaRESUMO
BACKGROUND: There is scarce evidence about the prognosis of venous thromboembolism in patients undergoing orthopedic surgery and in patients suffering non-surgical trauma. METHODS: We used the RIETE database (Registro Informatizado de pacientes con Enfermedad Trombo Embólica) to compare the prognosis of venous thromboembolism and the use of thromboprophylaxis in patients undergoing different orthopedic procedures and in trauma patients not requiring surgery. RESULTS: From March 2001 to March 2015, a total of 61,789 patients were enrolled in RIETE database. Of these, 943 (1.52%) developed venous thromboembolism after elective arthroplasty, 445 (0.72%) after hip fracture, 1,045 (1.69%) after non-major orthopedic surgery and 2,136 (3.46%) after non-surgical trauma. Overall, 2,283 patients (50%) initially presented with pulmonary embolism. Within the first 90 days of therapy, 30 patients (0.66%; 95% CI 0.45-0.93) died from pulmonary embolism. The rate of fatal pulmonary embolism was significantly higher after hip fracture surgery (n = 9 [2.02%]) than after elective arthroplasty (n = 5 [0.53%]), non-major orthopedic surgery (n = 5 [0.48%]) or non surgical trauma (n = 11 [0.48%]). Thromboprophylaxis was more commonly used for hip fracture (93%) or elective arthroplasty (94%) than for non-major orthopedic surgery (71%) or non-surgical trauma (32%). Major bleeding was significantly higher after hip fracture surgery (4%) than that observed after elective arthroplasty (1.6%), non-major orthopedic surgery (1.5%) or non-surgical trauma (1.4%). CONCLUSIONS: Thromboprophylaxis was less frequently used in lower risk procedures despite the absolute number of fatal pulmonary embolism after non-major orthopedic surgery or non-surgical trauma, exceeded that observed after high risk procedures.
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OBJECTIVE: Elevated physical activity has been observed in some patients with anorexia nervosa (AN) despite their emaciated condition. However, its effects on treatment outcome remain unclear. This study aimed to examine objectively measured physical activity in this clinical population and how it might be related to a partial hospitalization therapy response, after considering potential confounders. METHOD: The sample comprised 88 AN patients consecutively enrolled in a day hospital treatment program, and 116 healthy-weight controls. All participants were female and a baseline assessment took place using an accelerometer (Actiwatch AW7) to measure physical activity, the Eating Disorders Inventory-2 and the Depression subscale of the Symptom Checklist-Revised. Outcome was evaluated upon the termination of the treatment program by expert clinicians. RESULTS: Although AN patients and controls did not differ in the average time spent in moderate-to-vigorous physical activity (MVPA) (P=.21), nor daytime physical activity (P=.34), fewer AN patients presented a high physical activity profile compared to the controls (37% vs. 61%, respectively; P=.014). Both lower levels of MVPA and greater eating disorder severity had a direct effect on a poor treatment outcome. Depression symptoms in the patients were associated with lower MVPA, as well as with an older age, a shorter duration of the disorder and greater eating disorder psychopathology. CONCLUSIONS: There is a notable variation in the physical activity profile of AN patients, characterized by either low or very high patterns. Physical activity is a highly relevant issue in AN that must be taken into account during the treatment process.
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Anorexia Nervosa/terapia , Depressão/terapia , Exercício Físico , Satisfação do Paciente , Adolescente , Adulto , Anorexia Nervosa/complicações , Anorexia Nervosa/psicologia , Depressão/complicações , Depressão/psicologia , Feminino , Humanos , Pacientes Internados/psicologia , Masculino , Atividade Motora , Fatores de Tempo , Resultado do Tratamento , Adulto JovemRESUMO
BACKGROUND: Over the last 50 years, several studies have provided estimates of the prevalence of transsexualism. The variation in reported prevalence is considerable and may be explained by factors such as the methodology and diagnostic classification used and the year and country in which the studies took place. Taking these into consideration, this study aimed to critically and systematically review the available literature measuring the prevalence of transsexualism as well as performing a meta-analysis using the available data. METHODS: Databases were systematically searched and 1473 possible studies were identified. After initial scrutiny of the article titles and removal of those not relevant, 250 studies were selected for further appraisal. Of these, 211 were excluded after reading the abstracts and a further 18 after reading the full article. This resulted in 21 studies on which to perform a systematic review, with only 12 having sufficient data for meta-analysis. The primary data of the epidemiological studies were extracted as raw numbers. An aggregate effect size, weighted by sample size, was computed to provide an overall effect size across the studies. Risk ratios and 95% confidence intervals (CIs) were calculated. The relative weighted contribution of each study was also assessed. RESULTS: The overall meta-analytical prevalence for transsexualism was 4.6 in 100,000 individuals; 6.8 for trans women and 2.6 for trans men. Time analysis found an increase in reported prevalence over the last 50 years. CONCLUSIONS: The overall prevalence of transsexualism reported in the literature is increasing. However, it is still very low and is mainly based on individuals attending clinical services and so does not provide an overall picture of prevalence in the general population. However, this study should be considered as a starting point and the field would benefit from more rigorous epidemiological studies acknowledging current changes in the classification system and including different locations worldwide.
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Transexualidade , Estudos Transversais , Feminino , Humanos , Masculino , Prevalência , Transexualidade/diagnóstico , Transexualidade/epidemiologiaRESUMO
OBJECTIVE: Recently, the DSM-5 has developed a new diagnostic category named "Substance-related and Addictive Disorders". This category includes gambling disorder (GD) as the sole behavioral addiction, but does not include sex addiction (SA). The aim of this study is to investigate whether SA should be classified more closely to other behavioral addictions, via a comparison of the personality characteristics and comorbid psychopathology of individuals with SA with those of individuals with GD, which comes under the category of addiction and related disorders. METHOD: The sample included 59 patients diagnosed with SA, who were compared to 2190 individuals diagnosed with GD and to 93 healthy controls. Assessment measures included the Diagnostic Questionnaire for Pathological Gambling, the South Oaks Gambling Screen, the Symptom CheckList-90 Items-Revised and the Temperament and Character Inventory-Revised. RESULTS: No statistically significant differences were found between the two clinical groups, except for socio-economic status. Although statistically significant differences were found between both clinical groups and controls for all scales on the SCL-90, no differences were found between the two clinical groups. The results were different for personality characteristics: logistic regression models showed that sex addictive behavior was predicted by a higher education level and by lower scores for TCI-R novelty-seeking, harm avoidance, persistence and self-transcendence. Being employed and lower scores in cooperativeness also tended to predict the presence of sex addiction. CONCLUSIONS: While SA and GD share some psychopathological and personality traits that are not present in healthy controls, there are also some diagnostic-specific characteristics that differentiate between the two clinical groups. These findings may help to increase our knowledge of phenotypes existing in behavioral addictions.
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Comportamento Aditivo/psicologia , Jogo de Azar/psicologia , Comportamento Sexual , Adulto , Comportamento Cooperativo , Manual Diagnóstico e Estatístico de Transtornos Mentais , Escolaridade , Emprego , Comportamento Exploratório , Feminino , Redução do Dano , Humanos , Masculino , Transtornos Mentais/complicações , Pessoa de Meia-Idade , Testes Neuropsicológicos , Personalidade , Fatores Socioeconômicos , Inquéritos e QuestionáriosRESUMO
This study aimed to explore how track and field coaches respond to athletes with eating problems. Eleven experienced coaches participated in semi-structured interviews exploring their responses to, and challenges faced when, working with athletes with eating problems. The analysis revealed three themes relating to the strategies employed by coaches. The first theme indicated a supportive approach, where coaches were proactive in seeking support and in reducing training at the early stages of an eating problem. The second theme outlined an avoidant approach, characterized by coach reluctance to be involved in managing eating problems, and a lack of confidence in their knowledge of eating disorders. The third theme involved a confrontational approach, where coaches employed strict rules and engaged in coercion to persuade athletes to seek treatment. All of the coaches reported facing challenges in persuading athletes to seek treatment and were frustrated by the lack of available support. The study highlights the importance of providing resources and support services where coaches can seek advice. Coach-education packages can utilize the findings to highlight the strengths and limitations of different coach strategies, and to reinforce the importance of their role in identification and intervention when eating problems in athletes are suspected.
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Transtornos da Alimentação e da Ingestão de Alimentos/psicologia , Relações Interpessoais , Educação Física e Treinamento/métodos , Atletismo/psicologia , Adulto , Idoso , Atitude Frente a Saúde , Transtornos da Alimentação e da Ingestão de Alimentos/diagnóstico , Transtornos da Alimentação e da Ingestão de Alimentos/etiologia , Transtornos da Alimentação e da Ingestão de Alimentos/terapia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Pesquisa Qualitativa , Reino UnidoRESUMO
OBJECTIVE: A cognitive interpersonal maintenance model of anorexia nervosa (AN) was first proposed in 2006 and updated in 2013 (Schmidt and Treasure, J Br J Clin Psychol, 45, 343-366, 2006; Treasure and Schmidt, J Eat Disorders, in press.). The aim of this study was to test the interpersonal component of this model in people with AN requiring intensive hospital treatment (inpatient/day patient). METHOD: On admission to hospital women with AN or eating disorder not otherwise specified (AN subtype; n = 152; P) and their primary carers (n = 152; C) completed questionnaires on eating symptoms (P), depression and anxiety (P, C), accommodation and enabling (C), and psychological control (C). Structural equation modeling was used to examine relationships among these components. RESULTS: Carers' expressed emotion and level of psychological control were significantly related to carers' distress, which in turn, was related to patients' distress. This pathway significantly predicted eating symptoms in patients. DISCUSSION: The cognitive interpersonal maintenance model of eating disorders (EDs) was confirmed in part and suggests that interventions targeting interpersonal maintaining factors such as carer distress might impact on patient outcomes.
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Anorexia Nervosa/psicologia , Cuidadores/psicologia , Depressão/psicologia , Relações Interpessoais , Modelos Psicológicos , Adolescente , Adulto , Fatores Etários , Anorexia Nervosa/diagnóstico , Cuidadores/estatística & dados numéricos , Fatores de Confusão Epidemiológicos , Depressão/epidemiologia , Transtornos da Alimentação e da Ingestão de Alimentos/diagnóstico , Transtornos da Alimentação e da Ingestão de Alimentos/psicologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Psicometria , Controles Informais da Sociedade , Fatores Socioeconômicos , Inquéritos e Questionários , Reino Unido/epidemiologia , Adulto JovemRESUMO
This paper brings together the latest developments that have occurred in different aspects of venous thromboembolism (VTE): VTE prophylaxis in high-risk orthopedic surgery and acutely ill hospitalized medical patients; therapeutic advances in pulmonary embolism and superficial vein thrombosis and VTE future prospects. It summarizes the reviews that five speakers made in-depth for the Second Day in New Anticoagulant Treatment, held in Madrid on November 18, 2011, organized by the Foundation for the Study of Thromboembolic Disease in Spain and endorsed by the Spanish Society of Internal Medicine, Spanish Society of Pneumology and Thoracic Surgery, Spanish Society of Cardiology, Spanish Society of Thrombosis and Haemostasis and the Spanish Society of Angiology and Vascular Surgery.
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Anticoagulantes/uso terapêutico , Procedimentos Ortopédicos , Complicações Pós-Operatórias/prevenção & controle , Embolia Pulmonar/tratamento farmacológico , Tromboembolia Venosa/prevenção & controle , Trombose Venosa/tratamento farmacológico , Antitrombinas/uso terapêutico , Inibidores do Fator Xa , Humanos , Guias de Prática Clínica como Assunto , Tromboembolia Venosa/etiologia , Trombose Venosa/diagnósticoRESUMO
BACKGROUND: The evidence base for the treatment of adolescents with bulimia nervosa (BN) is limited. AIMS: To assess the feasibility, acceptability, and clinical outcomes of a web-based cognitive-behavioural (CBT) intervention for adolescents with bulimic symptomatology. METHOD: 101 participants were recruited from eating disorders clinics or from beat, a UK-wide eating disorders charity. The programme consisted of online CBT sessions ('Overcoming Bulimia Online'), peer support via message boards, and email support from a clinician. Participants' bulimic symptomatology and service utilisation were assessed by interview at baseline and at three and six months. Participants' views of the treatment package were also determined. RESULTS: There were significant improvements in eating disorder symptoms and service contacts from baseline to three months, which were maintained at six months. Participants' views of the intervention were positive. CONCLUSIONS: The intervention has the potential for use as a first step in the treatment of adolescents with bulimic symptomatology.
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Bulimia/terapia , Terapia Cognitivo-Comportamental/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Adolescente , Adulto , Bulimia/diagnóstico , Terapia Cognitivo-Comportamental/métodos , Feminino , Humanos , Internet , Masculino , Satisfação do Paciente/estatística & dados numéricos , Terapia Assistida por Computador/métodosRESUMO
BACKGROUND: Even though low molecular weight heparins (LMWHs) have become the standard for venous thromboembolism (VTE) prophylaxis in most European countries and Canada, it was not until recently that LMWHs were approved for use in the United States. The main objective of this study was to assess the current preferences and attitudes of United States surgeons toward the prevention of VTE with particular reference to LMWH. METHODS: A survey with questions relative to VTE awareness, risk factors, and prevention practices was mailed to 10,000 Fellows of the American College of Surgeons. RESULTS: A total of 1,145 (11.45%) usable questionnaires were returned. The vast majority (96%) of respondents use prophylaxis against VTE. Although LMWHs were rated first regarding efficacy and second regarding simplicity of use, conventional unfractionated heparin at fixed doses remains the preferred pharmacological agent for VTE prevention (74%), followed by 2 LMWHs: enoxaparin (34%) and dalteparin (16%). Overall, 52% of surgeons preferred physical methods over pharmacological methods when used separately and 26% of surgeons utilize combined physical-pharmacological modalities. CONCLUSIONS: North American general surgeons have substantially modified their approach to VTE prevention in the last 4 years. Physical methods and unfractionated heparin remain the preferred prophylactic modalities, but LMWHs have gained rapid acceptance since their approval for use for VTE prevention in North America. Even though the results of this survey must be interpreted with caution because of the limited response rate and possible sampling bias, they still reflect the current preferences and attitudes of North American surgeons toward prophylaxis.
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Anticoagulantes/uso terapêutico , Cirurgia Geral , Heparina de Baixo Peso Molecular/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Tromboembolia/prevenção & controle , Trombose Venosa/prevenção & controle , Anticoagulantes/economia , Atitude do Pessoal de Saúde , Bandagens/economia , Análise Custo-Benefício/economia , Pesquisas sobre Atenção à Saúde , Heparina de Baixo Peso Molecular/economia , Humanos , Incidência , Complicações Pós-Operatórias/epidemiologia , Guias de Prática Clínica como Assunto , Fatores de Risco , Índice de Gravidade de Doença , Inquéritos e Questionários , Tromboembolia/complicações , Tromboembolia/diagnóstico , Resultado do Tratamento , Ultrassonografia Doppler Dupla , Estados Unidos/epidemiologia , Trombose Venosa/complicações , Trombose Venosa/diagnósticoRESUMO
PURPOSE: The use of intermittent pneumatic compression, in addition to elastic bandages or stockings, accelerates the healing of leg ulcers in patients with severe chronic venous insufficiency (CVI). There is recent evidence that impulse compression of the plantar venous plexus reduces post-traumatic ankle swelling and prevents postoperative venous thromboembolism. The purpose of this study was to evaluate the clinical and hemodynamic responses after home use of impulse foot compression for 3 months in patients already using therapeutic compression stockings for the management of CVI. METHODS: Twelve extremities from 9 patients with documented CVI, class 4 to 5 according to the Clinical, Etiology, Anatomy, Pathophysiology classification system, were included in this prospective cohort study. All patients were instructed to use a foot pump device at home for 2 hours a day for 3 months in addition to therapeutic compression stockings (30-40 mm Hg) worn during the day. The device was set to three cycles (3 seconds) of compression (120 mm Hg) per minute. A clinical scoring system was completed before foot compression and 1, 2, and 3 months thereafter. In addition, all patients underwent air plethysmography studies at the same time intervals, including venous volume, venous filling index, ejection fraction, and residual volume fraction. RESULTS: Patients reported significant improvement in their scores for swelling (P <.05) and pain (P <.04). Air plethysmography showed a reduction in venous volume and venous filling index, although these differences were not significant. Ejection fraction remained unchanged and residual volume fraction was significantly reduced (P <.05) compared with baseline. The foot compression devices were well tolerated by all the patients in the study. CONCLUSIONS: The use of home foot impulse compression plus elastic stockings significantly reduced the residual volume fraction as measured by air-plethysmography in a group of patients with severe CVI. This favorable hemodynamic response could, in part, explain the clinical improvement achieved by this combined treatment. However, this represents a preliminary pilot study that needs to be confirmed in future randomized controlled studies with more patients included.
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Bandagens , Trajes Gravitacionais , Insuficiência Venosa/terapia , Estudos de Coortes , Feminino , Pé/irrigação sanguínea , Serviços Hospitalares de Assistência Domiciliar , Humanos , Perna (Membro)/irrigação sanguínea , Masculino , Pessoa de Meia-Idade , Pletismografia , Estudos Prospectivos , Fatores de TempoRESUMO
Effective and safe methods of preventing venous thromboembolism (VTE) are now widely available, but a significant proportion of patients develop VTE either because thromboprophylaxis has not been used or because the intensity of thromboprophylaxis is not matched to the level of risk. Thromboembolic risk varies widely according to the clinical setting and presence of underlying risk factors, but VTE may not be suspected even in high-risk patients. Clinical risk factors for VTE include recent surgery, cancer, stroke, previous VTE, immobilization, and advanced age. Recent attention has focused on the role of inherited and acquired molecular factors in determining overall thromboembolic risk. These factors include the classic thrombophilias-deficiencies of antithrombin III, protein C, and protein S-and several newly described molecular risk factors: factor V Leiden, the prothrombin 20210A gene mutation, and hyperhomocysteinemia. Based on emerging knowledge of risk factors, several risk assessment models (RAMs) have been devised that stratify patients according to overall VTE risk, allowing thromboprophylaxis to be tailored appropriately. Compared with older risk assessment formulas, current RAMs are simpler and include specific recommendations for thromboprophylaxis based on the available scientific evidence. Consensus documents on VTE prevention classify patients into low-, moderate-, and high-risk categories. More recently, a new risk group, very high risk, has been described. Very-high-risk patients are especially prone to thromboembolic complications and need intensive and in some cases prolonged thromboprophylaxis.
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Trombose Venosa/etiologia , Humanos , Medição de Risco , Fatores de Risco , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Tromboembolia/etiologia , Tromboembolia/prevenção & controle , Trombofilia/complicações , Trombose Venosa/prevenção & controleAssuntos
Sintomas Afetivos/diagnóstico , Transtornos do Comportamento Infantil/diagnóstico , Poder Familiar/psicologia , Equipe de Assistência ao Paciente , Medicina Estatal , Adolescente , Criança , Feminino , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Determinação da Personalidade , Atenção Primária à Saúde , Reino UnidoRESUMO
OBJECTIVE: To determine current perceived practice of consultant psychiatrists regarding taking a sexual history and management of sexual dysfunction of their patients. DESIGN: A postal questionnaire survey. PARTICIPANTS: A group of old age and general consultant psychiatrists. MEASURES: A questionnaire with two different case vignettes describing an elderly male complaining of low mood (the other vignette described a middle-aged man with the same complaint) and questions regarding taking a sexual history and management of sexual dysfunction. RESULTS: Response rate of 61% was obtained. Consultant psychiatrists (general and old age) take a sexual history much more frequently of middle-aged men than of elderly men (p<0.001). There are no statistically significant differences between the two groups of psychiatrists in their psychiatric assessment regarding taking sexual history and the management of sexual dysfunction in elderly men (p>0.05). Middle-aged men with sexual dysfunction are referred to a specialized clinic, whilst elderly men are referred to a community psychiatric nurse. CONCLUSIONS: These findings indicate that taking a sexual history is often omitted in the psychiatric assessment of elderly men. Elderly men with sexual dysfunction do not receive appropriate referral and treatment. Human sexuality and particularly aged sexuality is an area that requires more attention in psychiatric training.
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Avaliação Geriátrica , Psiquiatria Geriátrica/normas , Anamnese , Preconceito , Comportamento Sexual , Idoso , Feminino , Pesquisas sobre Atenção à Saúde , Humanos , Masculino , Competência Profissional , Fatores Sexuais , Disfunções Sexuais Fisiológicas/diagnósticoRESUMO
BACKGROUND: To evaluate the prevalence of thrombosis risk factors in a group of patients undergoing venous duplex scanning (VDS) and to design a risk factor stratification model with the ability to improve the diagnostic yield of VDS. METHODS: Risk factor assessment and VDS were performed on 1,000 patients with clinically suspected lower extremity deep vein thrombosis (DVT) and patients were divided into two groups based upon the outcome of their scan: those with and those without confirmed DVT. Univariate and multivariate logistic regression analyses were performed in order to determine the significance of each risk factor in relation to having a confirmed DVT. RESULTS: There were 181 patients (18.1%) with confirmed DVT. A prior history of DVT/pulmonary embolism, malignancy, prior immobilization, and age over 70 were the most important risk factors associated with having a DVT confirmed on VDS. A novel risk factor stratification model was created utilizing the odds ratios of those factors found to be significant and the prevalence of DVT was found to be 92.4% in the high risk category, 11.5% in the moderate risk category, and 3.2% in the low risk category using this model. CONCLUSIONS: Venous duplex scanning is established as the screening test of choice when one suspects the diagnosis of DVT despite the significant cost of performing and interpreting the test. We suggest that a better clinical model utilizing risk factor assessment may be the key to increasing the yield rate and cost-effectiveness of VDS by excluding low-risk patients from undergoing unnecessary testing.
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Medição de Risco/métodos , Ultrassonografia Doppler Dupla , Trombose Venosa/diagnóstico por imagem , Adulto , Idoso , Velocidade do Fluxo Sanguíneo , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Razão de Chances , Prevalência , Prognóstico , Fatores de Risco , Trombose Venosa/epidemiologia , Trombose Venosa/fisiopatologiaRESUMO
Patients undergoing orthopedic surgery are at increased risk of venous thromboembolic events. Proven prophylactic measures are available but are generally underused. However, even one of the most effective therapies available, low-molecular-weight heparin, fails to prevent deep vein thrombosis in approximately 15% of patients undergoing total hip replacement. Clinical outcomes and cost-effectiveness of venous thromboembolism prophylaxis may be optimized by tailoring the treatment to the level of risk of each patient. Overall thromboembolic risk depends on the interactions among multiple factors, such as those that relate to the current clinical status and underlying susceptibility of the patient. Presently, risk assessment models that consider these factors may be of practical assistance in stratifying patients. Improving identification of patients with additional risk factors is a goal of future models. Novel therapies, such as the recombinant hirudin desirudin, or strategies, such as prolonged postoperative prophylaxis, may provide improved protection in these patients and should be considered in the future.
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Anticoagulantes/uso terapêutico , Heparina de Baixo Peso Molecular/uso terapêutico , Complicações Pós-Operatórias/prevenção & controle , Trombose Venosa/prevenção & controle , Humanos , Procedimentos Ortopédicos , Valor Preditivo dos Testes , Medição de Risco/métodos , Fatores de RiscoRESUMO
OBJECTIVE: The purpose of this study was to assess the rate of deep vein thrombosis (DVT) resolution and DVT outcomes as functions of the level of oral anticoagulation therapy achieved with warfarin. METHODS: In 33 consecutive patients, a series of 35 limbs with acute symptomatic DVT was followed throughout 1 year of anticoagulation therapy. All the patients underwent 5 days of intravenous unfractionated sodium heparin therapy that was adjusted in dose to prolong the activated thromboplastin time to 2.0 to 2.5 times the control. In addition, warfarin was administered for a period of 6 months, with a target international normalized ratio (INR) between 2.0 and 3.0. All the patients underwent venous duplex scanning and physical examination at the time of diagnosis and at 1 week, 1 month, 3 months, 6 months, and 1 year. RESULTS: At the end of the 1-year study period, the rate of complete DVT resolution was 68%. The median INR values in patients with complete DVT resolution were significantly higher than those of patients with incomplete DVT resolution after 1, 3, and 6 months of treatment with warfarin. In addition, the proportion of patients with INR values below therapeutic range was significantly higher in patients with incomplete DVT resolution than in patients with complete DVT resolution after 1, 3, and 6 months of treatment with warfarin. The presence of occlusive thrombi was associated with incomplete DVT resolution. Of the patients with occlusive thrombi, 62% had chronic venous insufficiency symptoms develop, whereas only 11% of the patients with nonocclusive thrombi (P =.003) had these symptoms develop. CONCLUSION: Despite 6 months of oral anticoagulant therapy, almost one third of thrombi did not resolve completely. The INR values were significantly higher in those patients with complete DVT resolution. These results suggest that the maintenance of an INR level between 2.0 and 3.0 throughout oral anticoagulation therapy will minimize the rate of incomplete DVT resolution.
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Anticoagulantes/uso terapêutico , Trombose Venosa/tratamento farmacológico , Varfarina/uso terapêutico , Administração Oral , Idoso , Anticoagulantes/administração & dosagem , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Estudos Prospectivos , Tempo de Protrombina , Fatores de Tempo , Ultrassonografia Doppler de Pulso , Trombose Venosa/sangue , Trombose Venosa/diagnóstico por imagem , Varfarina/administração & dosagemRESUMO
PURPOSE: The purpose of this study was to assess the rate of postoperative deep vein thrombosis (DVT) as a function of oral anticoagulation therapy after total hip replacement surgery. METHODS: A total of 125 patients completed the study. All the patients received sequential gradient pneumatic compression over elastic stockings until hospital discharge. In addition, all the patients underwent postoperative heparin therapy followed by oral warfarin therapy, adjusted in dose to maintain a goal international normalized ratio (INR) level of 2.0 to 3.0. Warfarin therapy and compression stockings were continued for 1 month after surgery. Bilateral duplex scanning was performed 1 and 4 weeks after surgery to assess the rate of DVT. RESULTS: Nineteen of the 125 patients had DVT develop (15.2%). Of those thromboses, six (31.6%) and 13 (68%) were detected 1 week and 1 month after surgery, respectively. The rate of proximal DVT was 2.4% (3 of 125) 1 week after surgery and rose to 8.2% (10 of 122) 1 month after surgery. Most DVT cases (64%; 12 of 19) were asymptomatic. The patients in whom DVT developed had significantly lower INR values during the second to fourth postoperative weeks than did those patients without thrombosis, and no differences in INR values were found during the first postoperative week. CONCLUSION: The risk of the development of DVT extends beyond hospital discharge in patients who undergo total hip replacement, despite a regimen of prolonged oral anticoagulation therapy. This is particularly true in patients whose INR values did not reach therapeutic range during the first postoperative month. Therefore, thrombosis prophylaxis regimens on the basis of the administration of warfarin should try to maintain INR values within therapeutic range during the entire first postoperative month to minimize the incidence of DVT.